CoChat
Sign Up
Cited by 1,069Patient Safety and Medication ErrorsHospital Admissions and OutcomesClinical Reasoning and Diagnostic Skills

The DOI matches its Crossref record; 14 of the 14 references it cites were found in a registry or an index.

Communication Failures: An Insidious Contributor to Medical Mishaps

Sutcliffe, Kathleen M., Lewton, Elizabeth, Rosenthal, Marilynn M.·2004·Academic Medicine
DOI 10.1097/00001888-200402000-00019
Open this paper in CoChat — free account

Abstract

PURPOSE: To describe how communication failures contribute to many medical mishaps. METHOD: In late 1999, a sample of 26 residents stratified by medical specialty, year of residency, and gender was randomly selected from a population of 85 residents at a 600-bed U.S. teaching hospital. The study design involved semistructured face-to-face interviews with the residents about their routine work environments and activities, the medical mishaps in which they recently had been involved, and a description of both the individual and organizational contributory factors. The themes reported here emerged from inductive analyses of the data. RESULTS: Residents reported a total of 70 mishap incidents. Aspects of "communication" and "patient management" were the two most commonly cited contributing factors. Residents described themselves as embedded in a complex network of relationships, playing a pivotal role in patient management vis-à-vis other medical staff and health care providers from within the hospital and from the community. Recurring patterns of communication difficulties occur within these relationships and appear to be associated with the occurrence of medical mishaps. CONCLUSION: The occurrence of everyday medical mishaps in this study is associated with faulty communication; but, poor communication is not simply the result of poor transmission or exchange of information. Communication failures are far more complex and relate to hierarchical differences, concerns with upward influence, conflicting roles and role ambiguity, and interpersonal power and conflict. A clearer understanding of these dynamics highlights possibilities for appropriate interventions in medical education and in health care organizations aimed at improving patient safety.

Overview

Integrity signals

Registry

Crossref · 10.1097/00001888-200402000-00019

Cites

14 of 14 references verified0 citation errors · 0 not checkable

Statistics

Recomputing p-values needs the paper’s full text.

Verification

Claims the paper makes

This paper’s full text isn’t openly available, so its claims and self-check weren’t run. The registry and citation checks still apply.

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Citations

Cites

Research works printed but not linked: 2

  1. Thomas, 1999, Inquiry, 36, 255
  2. Duldt, 1981, Nurs Outlook, 29, 640

Cited by

Sorted by citations

See all 1,069

Related

See all

Metadata

Authors
Sutcliffe, K. M., Lewton, E., & Rosenthal, M. M.
Affiliations
University of Michigan (US)
Corresponding author
Sutcliffe, Kathleen M.
Venue
Academic Medicine
Publisher
Oxford University Press (OUP)
Published
2004-02
Volume
79
Issue
2
Pages
186-194
ISSN
1040-2446 (ISSN-L)
DOI
10.1097/00001888-200402000-00019
OpenAlex
W2033026182
Cited by
1,069
References
14
Citations by year
2026: 43 · 2025: 35 · 2024: 31 · 2023: 39 · 2022: 35 · 2021: 61 · 2020: 55 · 2019: 55 · 2018: 57 · 2017: 61 · 2016: 74 · 2015: 66 · 2014: 67 · 2013: 72 · 2012: 58
FWCI
32.77
Type
journal article
Language
en
Open access
closed
Locations
  • Academic Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • Deep Blue (University of Michigan) (submittedVersion)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Patient Safety and Medication Errors
  • Health Sciences › Nursing › Leadership and Management › Hospital Admissions and Outcomes
  • Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
Keywords
communication breakdown, medical errors, patient safety, medical residents, clinical management, organizational factors, role ambiguity, health care organization, medical education
MeSH terms
Adult, Clinical Competence, Communication, Female, Hospitals, Teaching, Humans, Internship and Residency, Interprofessional Relations, Interviews as Topic, Male, Patient Care Management, Physician-Patient Relations, Physician's Role, Random Allocation, Sampling Studies, United States, Medical Errors

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review